Policy Holders Name, Address, & Phone number if different than patient:

M A N H A T T A N O R T H O P E D I C & S P O R T S M E D I C I N E G R O U P , P C

1065 Park Avenue New York, NY 10128 212.289.0700

Fax: 212.289.0171

WORKER

Edmond Cleeman, M.D. Craig DuShey, M.D. Marvin S. Gilbert, M.D. Richard S. Gilbert, M.D. Mark J . Klion, M.D.

Vikas Varma, M.D.

27-31 Crescent Street Long Island City, NY 11102

718.204.0548 Fax: 718.504.4928

'S COMPENSATION INFORMATION SHEET Please complete onlv the highlighted areas

Patient's Name: Employer:

Employer's Address: jjjjjjjjjjjjljjjjjj^^

Employer's Phone #: Date of Accident: Carrier Case #

Workers Compensation #: Insurance Carriers Name: Insurance Address:

Insurance Phone #: Case Worker's Name:

DOWNSTATE CENTRALIZED MAILING 100 Broadway State Office Building 295 Main Street

(for New York City, Hempstead, HauppaugeS Peekskill Districts) Menands 44 Hawley Street Suite 400 130 Main Street W. 935 James St.

P O B o x 5 2 0 5 Binghamton,NY13902-5205 ALBANY 12241 BINGHAMTON 13901 BUFFALO 14203 ROCHESTER 14614 SYRACUSE 13203 NYC (800)877-1373 /Hemp. (866)805-3630 / Haup. {866)681-5354 /Peek. (866)746-0552 (866) 750-5157 (866) 802-3604 (866) 211-0645 (866) 211-0644 (866) 802-3730

State of New York

WORKERS' COMPENSATION BOARD

CLAIMANT'S AUTHORIZATION TO DISCLOSE WORKERS' COMPENSATION RECORDS

PLEASE COMPLETE A L L ITEMS. AN INCOMPLETE FORM WILL DELAY THE PROCESSING OF YOUR REQUEST. Claimant's Name Claimant's Social Security No. Case Number • W C B Q D B •Discrimination

and/or Date of Accident

IF RELEASE IS AUTHORIZED FOR ADDITIONAL CASE FILE(S), IDENTIFY BELOW BY WCB/DB/DC CASE NUMBER AND/OR DATE OF ACCIDENT(S).

CLAIMANT IS PROHIBITED FROM AUTHORIZING RELEASE OF WORKERS' COMPENSATION INFORMATION TO PROSPECTIVE EMPLOYERS OR IN CONNECTION WITH ASSESSING FITNESS OR CAPABILITY OF EMPLOYMENT.

INSTRUCTIONS:

S u b m i t original to the Workers' C o m p e n s a t i o n Board and retain a c o p y for y o u r r e c o r d s . Authorization for disclosure of records for certain purposes is not valid under the law. See excerpt of WCL Section 110-a on the reverse of this form. This authorization is effective until it is revoked by the claimant. Claimant m a y revoke this authorization at any time u p o n written notice to the W o r k e r s ' C o m p e n s a t i o n B o a r d .

THIS AUTHORIZATION DOES NOT PERMIT YOU TO OPEN AN INDIVIDUAL eCASE ACCOUNT OR TO VIEW CASES VIA eCASE OUTSIDE OF A BOARD LOCATION.

~ l P u r s u a n t to Section 110-a of the W o r k e r s ' C o m p e n s a t i o n Law, I,

Claimant's Name

r e p r e s e n t that I am a person w h o is/was the subject of t h e W o r k e r s ' C o m p e n s a t i o n case(s) indicated a b o v e , a n d I authorize the W o r k e r s ' C o m p e n s a t i o n Board to discuss the a b o v e - r e f e r e n c e d W o r k e r s ' C o m p e n s a t i o n B o a r d records with and/or release a c o p y of the a b o v e - r e f e r e n c e d records to

at Name of a Specific Person, Corporation, Association or Public or Private Entity

Address

I u n d e r s t a n d that the requesting party may be required to pay a statutory fee prior to being provided c o p i e s of t h e s e records by the W o r k e r s ' C o m p e n s a t i o n Board.

L

J

Failure to provide the information requested on this form will not result in the denial of your authorization, but may delay the processing of your request. The voluntary release of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your request.

E m p l o y e e C l a i m

State of New York • Workers' Compensation Board

C - 3

I k ij§)' M Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Type or print neatly. This form may also be filled out on-line at w w w . w c b . s t a t e . n y . u s .

WCB Case Number (if you know it):

A. YOUR INFORMATION (Employee)

1. Name: . — 2. Date of Birth:

3. Mailing address:.

Number and Slreel/PO Box

4. Social Security Number:.

City

5. Phone Number: i

State Zip Code

6. Gender: Male I I Female 7. Will you need a translator if you have to attend a Board hearing? • Yes • No If yes, for what language?,

B. YOUR EMPLOYER(S)

1. Employer when injured:. 2- P n o n e Number:

3. Your work address: 4. Date you were hired:.

Number and Street

5. Your supervisor's name:.

City Zip Code

6. List names/addresses of any other employer(s) at the time of your injury/illness:

7. Did you lose time from work at the other employment(s) as a result of your injury/illness? D Yes D No

C. YOUR JOB on the date of the injury or illness

1. What was your job title or description?

2. What types of activities did you normally perform at work?

3. Wasyourjob?(checkone) • Full Time • Part Time • Seasonal • Volunteer • Other: 4. What was your gross pay (before taxes) per pay period? 5. How often were you paid? . 6. Did you receive lodging or tips in addition to your pay? O Yes Q No If yes, describe:

D. YOUR INJURY OR ILLNESS

1. Date of injury or date of onset of illness: / / 2. Time of injury: • AM D PM 3. Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)

4. Was this your usual work location? D Y e s D No If no, why were you at this location?

5. What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report)

6. How did the injury/illness happen? (e.g., I tripped over a pipe and fell on the floor)

7. Explain fully the nature of your injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):

YOUR NAME: DATE OF INJURY/ILLNESS:

First Ml Last

D. YOUR INJURY OR ILLNESS

8. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness? DY e s D No If yes, what? 9. Was the injury the result of the use or operation of a licensed motor vehicle? Q Yes Q No

If yes, Q your vehicle Q employer's vehicle D other vehicle License plate number (if known): _ If your vehicle was involved, give name and address of your motor vehicle insurance carrier:

10. Have you given your employer (or supervisor) notice of injury/illness? Oyes D No

If yes, notice was given to: j-J 0 ra 11 y D in writing Date notice given:.

11. Did anyone see your injury happen? Q Yes • No • Unknown If yes, list names:

/

E. RETURN TO WORK

1. Did you stop work because of your injury/illness? • Yes, on what date? / / • No, skip to Section F. 2. Have you returned to work? • Yes • No If yes, on what date? / / • regular duty • limited duty 3. If you have returned to work, who are you working for now? D Same employer D New employer D Self employed 4. What is your gross pay (before taxes) per pay period? How often are you paid?

F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS

1. What was the date of your first treatment? / / • None received (skip to question F-5) 2. Were you treated on site? • Yes • No

3. Where did you receive your first off site medical treatment for your injury/illness? Q none received Q Emergency Room

D Doctor's office D Clinic/Hospital/Urgent Care D Hospital Stay over 24 hours Name and address where you were first treated:

Phone Number: 4. Are you still being treated for this injury/illness? CZI Yes CD No

Give the name and address of the doctor(s) treating you for this injury/illness:

Phone Number: I 5. Do you remember having another injury to the same body part or a similar illness? LJYes L J No

If yes, were you treated by a doctor? Q Yes EJ No If v e s> provide the names and addresses of the doctor(s) who treated

you and COMPLETE AND FILE FORM C-3.3 TOGETHER WITH THIS FORM:

6. Was the previous injury/illness work related? L J Yes CJ No

If yes, were you working for the same employer that you work for now? Q yes L~J No

I am hereby making a claim for benefits under the Workers' Compensation Law. My signature affirms that the information I am providing is true and accurate to the best of my knowledge and belief.

Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or "by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any materialfact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.

Employee's Signature: Print Name: Date: / / On behalf of Employee: Print Name: Date: / /

An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.

i certify to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the allegations and other factual matters asserted above nave evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigations or discovery. Signature of Attorney/Representative (if any): Date: / / Print Name: Title:

ID No., if any: R If Licensed Representative, License No.: Expiration Date: / /

NOTICE THAT YOU MAYBE RESPONSIBLE FOR MEDICAL COSTS IN THE EVENT OF

FAILURE TO PROSECUTE, OR IF COMPENSATION CLAIM IS DISALLOWED, OR IF

AGREEMENT PURSUANT TO WCL §32 IS APPROVED

WCB CASE NO. (If Known) CARRIER CASE NC . (If Known) DATE OF INJURY NATURE OF INJURY OR

ILLNESS INJURED PERSON'S S O C SEC. NO.

CLAIMANT NAME ADDRESS APT. NO.

EMPLOYER INSURANCE CARRIER

You may become responsible for the medical costs of treatment for your illness or condition with the

provider listed below if (1) you fail to prosecute the claim for workers' compensation or (2) it is

determined by the Workers' Compensation Board that the illness or condition which required treatment

was not a result of a compensable workplace accident or occupational disease or (3) if an agreement is

executed by you and approved pursuant to Workers' Compensation Law §32 in which you waive your

right to medical benefits from the workers' compensation carrier/self-insured employer for treatment/

services performed after the date the agreement is approved. If any of the above events occurs, the

provider may bill you directly instead of the employer or insurance carrier, and you will be responsible

for the provider's fees for services rendered.

I hereby acknowledge that I have read the above and understand the circumstances under which I may

become responsible for payment.

Claimant's Signature Date

Provider's Name and Address

TO THE CLAIMANT

Workers' Compensation Board Regulation 325-1.23 permits your doctor or therapist to request that you sign this A-9 notice. By signing this notice, you acknowledge your obligation to pay the provider's fees for the services you receive if it turns out that such fees are not legally required to be paid by your employer or its workers' compensation insurance carrier and if such fees are not covered by other insurance. The employer or carrier may not be required to pay the doctor's fees if, for example, you fail to file a claim for workers' compensation, or fail to notify your employer of your injury or illness, or fail to attend a Board hearing if your employer challenges your right to benefits. Even if you make all required efforts to prosecute your claim, the Workers' Compensation Board may still find that you are not entitled to benefits. In such cases, this notice advises your health provider that you acknowledge your personal liability for payment of his/her bills.

Workers' Compensation Law Section 32

The A-9 notice also covers instances in which a claimant with an existing valid workers' compensation case comes to an agreement with his/her employer or its insurance carrier settling his/her case in accordance with Section 32 of the Workers' Compensation Law. A Section 32 agreement may include a provision which relieves the employer or carrier of the liability to pay future medical bills associated with the case. Your health care provider may ask you to sign this A-9 notice to insure that you acknowledge your personal liability for payment of his/her bills if you have waived your right to future medical benefits under a Section 32 agreement.

If you have any questions, contact your attorney or licensed hearing representative, if you have one. You may also contact your local district office of the Workers' Compensation Board.

TO THE HEALTH CARE PROVIDER

This notice is meant to advise the workers' compensation claimant that he/she may be responsible for payment. Failure of the claimant to sign this form does not relieve the provider of the obligation to treat the claimant, nor does it negate the claimant's responsibility for payment.

Keep the original of this form for your records and give a copy to the claimant. Do not file with the Workers' Compensation Board. You will receive Notices of Decisions in which the compensability of a claim, authorization of treatment, or payment of medical bills is included. You will also be notified if the claimant submits a Section 32 Agreement with the Board for approval. Do not bill the claimant unless and until you receive a Board decision finding that 1) claimant failed to prosecute the claim, or 2) the claim is denied, or 3) the treatment is not causally related to the work injury, or 4) a Section 32 agreement relieving the carrier of liability for medical treatment is approved.

Prescribed by Chair

A-9 (1-07)

NY-WCB

* ' State of New Y o r k (www.wcb.sta'te.ny.us)

Pursuant to Workers' Compensation Law Section

110

-a:

3. Individual authorization. Notwithstanding the restrictions on disclosure set forth under subdivision

one of this section, a person who is the subject of a workers' compensation record may authorize

the release, re-release or publication of his or her record to a specific person not otherwise

authorized to receive such record, by submitting written authorization for such release to the board

on a form prescribed by the chair or by a notarized original authorization specifically directing the

board to release workers' compensation records to such person. However, in accordance with

section one hundred twenty-five of this article, no such authorization directing disclosure of records

to a prospective employer shall be valid; nor shall an authorization permitting disclosure of records

in connection with assessing fitness or capability for employment be valid, and no disclosure of

records shall be made pursuant thereto. It shall be unlawful for any person to consider for the

purpose of assessing eligibility for a benefit, or as the basis for an employment-related action, an

individual's failure to provide authorization under this subdivision.

4.

It shall be unlawful for any person who has obtained copies of board records or individually

identifiable information from board records to disclose such information to any person who is not

otherwise lawfully entitled to obtain these records.

5. Any person who knowingly and willfully obtains workers' compensation records which contain

individually identifiable information under false pretenses or otherwise violates this section shall be

guilty of a class A misdemeanor and shall be subject upon conviction, to a fine of not more than one

thousand dollars.

6. In addition to or in lieu of any criminal proceeding available under this section, whenever there

shall be a violation of this section, application may be made by the attorney general in the name of

the people of the state of New York to a court or justice having jurisdiction by a special proceeding

to issue an injunction, and upon notice to the defendant of not less than five days, to enjoin and

restrain the continuance of such violations; and if it shall appear to the satisfaction of the court or

justice that the defendant has, in fact, violated this section, an injunction may be issued by such

court or justice, enjoining and restraining any further violation, without requiring proof that any

person has, in fact, been injured or damaged thereby. In any such proceeding, the court may make

allowances to the attorney general as provided in paragraph six of subdivision (a) of section

eighty-three hundred eighty-three of the civil practice law and rules, and direct restitution. Whenever the court

shall determine that a violation of this section has occurred, the court may impose a civil penalty of

not more than five hundred dollars for the first violation, and not more than one thousand dollars for

the second or subsequent violation within a three year period. In connection with any such

proposed application, the attorney general is authorized to take proof and make a determination of

the relevant facts and to issue subpoenas in accordance with the civil practice law and rules.